
Class Vfjlj^t 

Book -F3 

Gopyrightll? 



COPYRIGHT DEPOSIT 



THE 

Sphygmomanometer 

"^6 5- 



AND JLX-O 



Its Practical Application 



PP 

PREPARED FOR 

Students and Practitioners of Medicine 

BY 

FRANCIS ASHLEY FAUGHT, M. D. 

Director of the Laboratory of Clinical Medicine, Medico Chirurgical 

College and Hospital. Author of Essentials of 

Laboratory Diagnosis, Etc., Etc., 



Containing One Full Page Plate and Numerous Explanatory 
Diagrams in the Text 



Copyright, icou 

BY 

Francis Ashley Faught 



PUBL1SHED BY 

GEO. P. PILLING & SON CO. 

PHILADELPHIA 

1909 



A fV 




© SEP 2^ 1909 

c« k 2477 54 
SEP 28 1909 



CHAPTER I. 

THE CIRCULATION. 
A— COURSE OF THE BLOOD. 

In 1616 William Harvey published in the notes of his 
lectures his discovery of the circulation of the blood. Here 
he states that "a perpetual movement of the blood in & 
circle is caused by the beat of the Heart." 




Fig. 1. 

Fig. 1. Diagram of Circulation : Arrows indicate the course of 
the blood; P. A., Pulmonary Artery; P. C, Pulmonary Capillaries; P. 
V., Pulmonary Veins; L. A., Left Auricle; L. V., Left Ventricle; A., 
Systemic Arteries ; C. ; Systemic Capillaries ; V., Systemic Veins ; R. 
A., Right Auricle; R. V., Right Ventricle. (Redrawn from Am. Text 
Book of Physiology.) 

In the human body we may traee-the course of a given 
particle of blood as it leaves the right-ventricle until, having 



The Sphygmomanometer 



traversed the entire cardiovascular system, it returns to the 
starting point. Referring to Fig. I we find the course 
of the blood to be as follows : From the trunk of the pulmon- 
ary artery through a succession of arterial branches into 
the capillaries of the lungs, from these through the several 
branches of the pulmonary vein to the left auricle of the 
heart, thence through the mitral valve to the left ventricle, 
then by way of the aortic valve to the aorta and the general 
arterial tree until it finally reaches the capillaries. From 
the capillaries into the veins back toward the heart, through 
the vena cavae and into the right auricle, through the tri- 
cuspid valve into the right ventricle, through the pulmonary 
valve into the pulmonary artery, where the tracing of the 
circuit began. 

In brief, the vascular system is a closed series of tubes 
of varying diameters, including a force pump. This tubular 
system is partially interrupted at two points by a series of 
very minute vessels, the capillaries of the lung and of the 
general circulation. 

B— THE FLOW OF BLOOD. 

The condition of the arterial walls and the width of the 
arteries exercise considerable influence upon the flow of 
blood. If all the arteries of the body were fully dilated it 
would be absolutely impossible for the heart to maintain 
the circulation, because the relative 1 }- small amount of 
blood in the body could not begin to completely All the ves- 
sels. The caliber of the arteries is influenced mainly by re- 
flexes coming from various parts of the body, including 
the heart and the blood vessels themselves. Stimulation of 
a peripheral nerve will normally cause a reflex contraction 
which will tend to raise blood pressure. 

C— THE CAUSES OF THE FLOW OF BLOOD. 

The force by which the blood is driven from the right 
to the left side of the heart, through the capillaries which are 
related to the respiratory surface of the lung, is nearly all 
derived from the contraction of the muscular wall of the 
right ventricle. The force by which the blood is driven from 
the left side of the heart through the p-eneral circulation, in- 
cluding all the other capillaries in the body, is nearly all de- 



T H E SPH YC.MOM A NO M ETF.R 



rived from the contractions of the muscular wall of the left 
ventricle. The contraction of the two ventricles is simul- 
taneous. The force generated by the heart in maintaining 
the circulation is. to a subordinate degree, supplemented by 
the aspirating action of the chest wall during the respira- 
tory act, by the pumping action of the skeletal muscles and 
by the elasticity or tone of the arteries themselves. 

D— MECHANICS OF THE PUMPING MECHANISM. 

During each contraction or systole of the ventricles, 




Fig. 2. 

Fig. 2. Diagrammatic representation of the cavities of the heart, 
showing position of the valves during systole: P. A.. Pulmonary Artery ; 
F. V., Pulmonary Veins; L. A., Left Auricle; L. V., Left Ventricle; 
A.. Aorta; I. V., Inferior Vena Cava; S. A., Superior Vena Cava ; R. 
A., Right Auricle; R. V.. Right Ventricle. 



The Sphygmomanometer 



blood is forced into the arteries, only because, at that time, 
the auriculo-ventricular openings are closed by their res- 
pective valves. ( Fig. 2. ) Immediately following systole, dili- 
tation and relaxation of the walls of the ventricles occur. This 
constitutes diastole : at this time blood enters the ventricles 
from the arteries only because during diastole the exits from 
the ventricles are each closed by a valve which was open 
during ventricular systole, and because the auriculo-ventricu- 
lar valves which were closed during ventricular systole are 
now open. 

During the first and longer part of diastole of the ven- 
tricles, the auricles are also in diastole and the whole heart 
is in repose. Near the end of ventricular diastole, a brief 
simultaneous systole of both auricles occurs, during which 
they contract and drive the blood which has entered them 
from the systemic and pulmonary veins, into the ventricles. 
The systole of the auricles ends immediately before that of 
the ventricles begins. The brief systole of the auricles is 
succeeded by their long diastole which corresponds in time 
with the whole of the ventricular systole and a great part of 
ventricular diastole. During diastole of the auricles blood 
is entering them from the veins. Thus it is evident that 
the direction and force of the blood through the heart is 
entirely dependent upon the mechanism of the valves at the 
openings of the ventricles, and that the normal blood pres- 
sure is maintained in the circulatory system by the same 
means, aided by the resistance of the capillaries and the 
normal tone of the arteries, and that alterations in the circu- 
lation, and consequently in blood pressure, are very likely to 
follow disease of this mechanism, be it either in the valves 
themselves or in the musculature of the heart chambers. 

E— THE CAUSES OF PRESSURE IN THE ARTERI-AL 

SYSTEM. 

i — Resistance. 

The extensive ramification of the arterial system from 
the heart to the periphery, culminates in innumerable ar- 
terioles on the confines of the capillary system. ' In the 
course of the onward flow of blood through this vast system 
of minute tubules considerable friction is generated between 



T he Sphygmomanometer 



the blood and the vessel walls. The effect of this friction 
is propagated backward according to the physics of fluid 
pressure, and constitutes a strong force of resistance to the 
outward movement of blood from the heart itself. Thus 
at each ventricular systole the heart must raise the pressure 
within its cavity to a point higher than that existing in the 
aorta before it can deliver its charge through the aortic 
orifice. 

2 — Power. 
Where the aorta springs from the heart the rhythmic 
contraction of the left ventricle opens the aortic leaflets and 
forces intermittent charges of blood into the arterial system. 
The walls of the arteries are everywhere elastic and there- 
fore expand under the force of this sudden increase in pres- 
sure, thus some of the energy expended by the heart be- 
comes potential in the stretched arterial walls. 

3 — Elasticity. 
That the pressure in the arterial system is continuous, 
depends upon the capacity of the vessel walls for distension 
under sudden stress and gradual contraction as the pressure 
within the vessel is lowered by the onward passage of blood 
through the capillaries. 

F— BLOOD PRESSURE REGULATING MECHANISM. 

Normal blood pressure depends upon the normal corre- 
lation and interaction of certain variable factors. I — The 
amount of blood pumped into the arterial system by the 
heart. 2 — The resistance offered to the escape of blood to- 
ward the periphery through the smaller arteries and the 
capillaries. Of less importance are (3) the elasticity of the 
vessel walls and (4) the total quantity of blood in the body. 
These factors are all capable of interaction in the most 
complicated manner. For example, if the arterial pres- 
sure is increased from any cause, the vagus nerve is stimulat- 
ed, and the effect of its inhibitory action upon the heart 
is to lower the heart rate so that less blood is delivered into 
the aorta in a given time, thus assisting to maintain normal 
blood pressure. In like manner when the volume of blood is 
rapidly reduced from hemorrhage or venesect'on, the blood- 
vessel reflex immediately reduces the calibre, so that within 
certain limits the blood pressure is not altered. 



The Sphygmomanometer 



Arterial Tonus. 

It is recognized that the normal degree of contraction 
of the arteries — their tonus is mainly dependent upon ner- 
vous impulses which the vessels receive. Recent observa- 
tions have also demonstrated an independent muscular tone 
which controls the contraction of the arterial muscular coat, 
thereby maintaining some degree of contraction entirely 
independent of reflex action. 

If the arteries leading to any part of the body dilate or 
contract the blood supply to that part will be altered. It 
is important to remember in this connection that if the tonus 
of extensive vascular areas is altered the effect is not as 
easily neutralized as when small areas are involved, and, 
therefore, the general blood pressure will be affected. For 
this reason the condition of the numerous abdominal vessels, 
innervated by the splanchnic nerves — the so-called splanchnic 
area, on account of their great capacity when dilated, are 
of vital importance in the maintenance of normal blood 
pressure. 

G— BALANCE OF THE FACTORS IN MAINTAINING 
ARTERIAL PRESSURE. 

Considering a partially filled arterial system let us ob- 
serve what occurs when a volume of blood is projected into 
this system by the ventricular systoles. In the beginning 
the elastic walls of the vessels make room for this charge 
by expanding, while some accommodation is obtained by the 
onward passage of blood toward the capillaries. Since it 
is easier for the arteries to expand than for the whole mass 
of blood to pass on through the capillaries, the increments of 
blood are largely stored in the arterial system, thereby 
tending, by the increasing tension of the arterial walls, to 
increase blood pressure. Up to a certain point it is easier 
for the accommodation to occur by further expansion. 
When the capacity of the arteries to expand under pressure 
is approached the stretched muscular coat will become tense 
and stiff. Now at this point each systole will drive a larger 
portion of the blood forward through the capillaries, and an 
increasingly smaller amount will he stored in the vessels by 
a further yielding- of the wall. Normal conditions of pres- 
sure will be reached and maintained when the blood accom- 



The Sphvgmom anom eter 



modated at each systole by arterial expansion exactly equals 
the amount of blood passing- through the capillaries during 
the cardiac cycle. When this balance of forces occurs the 
blood pressure will be maintained at normal. 

Anything altering" this relation, either by increasing 
the output of the ventricle or by obstructing- the flow 
through the capillaries, or vise versa, will cause the blood 
pressure to change. The same is true of alterations in the 
normal elasticity of the arterial system. 

Thus during each cardiac cycle, the heart muscle does 
work in maintaining the capillary flow against capillary 
resistance, and in causing expansion of the arterial 
wall. A part of the manifest energy of the heart thus be- 
comes for a time potential in the stretched fibres of the 
arterial wall. The moment that a systole is at an end, the 
stretched elastic fibres recoil, and continue the work of the 
heart in maintaining the arterial flow against capillary re- 
sistance. As this potential energy becomes expanded the 
pressure gradually falls and it would eventually reach 
zero were it not for the rhythmically recurring cardiac 
systole which causes the pressure to again rise. 

H— METHOD OF STUDYING BLOOD PRESSURE. 

The use of manometers or upright tubes filled with 
fluid, in the study and measurement of blood pressure in 
man is attributed to an English clergyman, Stephen Hales, 1 
who published the results of his experiments in 1733. 

I— THE MANOMETER. 

The height of the manometric column is the true meas- 
ure of the pressure which supports it. The height of this 
sustained column will, according to the laws of physics, 
vary with the nature of the fluid composing the column. 
For example, a given pressure will sustain a column of 
water of greater height than a column of blood, and the 
column of mercury sustained by the same pressure will be 
much shorter than the column of blood. 

On account of the difficulties in the way of doting, 
and the fact that in man it is impracticable to employ the 

(1) Statistical Essays, London, 1733, vol. ii. p. 1. 



The Sphygmomanometer 



direct method, therefore the use of a column of blood must 
be reserved for use in the physiologic laboratory. By the 
indirect method a column of water may be successfully 
used, but is not practical because of the great length of tube 
needed to contain the water even with normal pressures. 

In 1828 a French physician named Poiseuille 2 devised 
a method of using a fluid heavier than either water or blood. 
He thereby secured a manageable manometer, a longer period 
of observation and a shorter colunm. 

The Mercury Manometer. 

The mercury manometer of to-day is a modification 
of the original made by Poiseuille. ( Fig. 3. ) In its improved 



§r^> 




FlG - 3- 

Fig. 3. Type of Mercury Manometer, employing "L tube ; A 
and B are for connection with the Armlet and Bellows respectively. 

form it consists of a glass tube open at both ends, bent into 
the form of an "U" with long limbs. This is securely 
fastened in a vertical position, partly filled with mercury, 
and fitted with a millimeter scale to measure the height of 
the mercurv column. 



(2) J. L. M. Poiseulle "Reeherches sur la force du a cur ac.rlique." Paris, 1828. 



The Sphygmomanometer 



J— THE ARTERIAL PULSE. 

The increase of --arterial pressure occurring at the 
peak of each ventricular systole and the diminishing pres- 
sure occurring during diastole constitute the main phe- 
nomena in the production of the arterial pulse. This fluctua- 
tion is shown in the manometer by a rhythmic oscillation of 
the mercury column synchronous with the beat of the heart. 

The arterial pressure and the pulse are maintained by 
and are dependent upon the volume and frequency of the 
charges of blood sent by the heart into the arterial system, 
and by the friction of the vessel walls and their elasticity. 

Upon a knowledge of these physiologic facts, and the 
infinite variations to which they arc subject, is based our 
knowledge of the pathology of the circulation and of blood 
pressure. 



CHAPTER II. 

BLOOD PRESSURE. CLINICAL VIEW. DEFINITIONS. 
CAPILLARY BLOOD PRESSURE. 

The pressure of the blood in the capillaries is low be- 
cause of the resistance offered to the progress of the blood 
by the fine bore of the vessels, and because of the relative 
large cross sectional area of all the capillaries compared 
to that of the aorta and great vessels. 

If one press with a blunt object upon the skin just be- 
low the matrix of the finger nail, the ruddy surface becomes 
pale because the capillaries are flattened by the force applied 
and the blood driven out of them. If delicate weights or a 
spring be used to apply the pressure, then the force which is 
just sufficient to whiten the tissues can be measured, and the 
amount of pressure which approximately counterbalances 
the pressure within the capillaries can be definitely deter- 
mined. 

The capillary pressure, measured by this means, has 
been found to be much lower than in the arteries, and con- 
siderably higher than the pressure in the great veins. This 
pressure has been found to equal that required to sustain 
a column of from 24 to 54 millimeters of mercury. 3 

Terms and Definitions. 

Having studied the physiology of the normal circula- 
tion, and the causes concerned in the production and main- 
tenance of blood pressure, we may now proceed to a con- 
sideration of the relation of these facts to the problems of 
clinical medicine, and their bearing on Diagnosis, Prognosis 
and Treatment. 

To obtain a clear insight and understanding of the 
subject it is all important to have an accurate knowledge of 
the terms applied to the matter under consideration. 

The Pulse. Is the rhythmically recurring impulse 
propagated bv the systole of the left ventricle and palpable 
throughout the arterial system. 

fS) Am. Joun. of Physiol, p 377. 



The Sphyc.mom anom eter 



U 



the degree 



Arterial Pressure. By arterial pressure is meant 
of force exerted by the blood within the 
vessel. It is primarily dependent on the strength of the 
heart as measured by its rate and by the volume of blood ex- 
peded at each systole, balanced by the elasticity of the ves- 
sel walls and capillary resistance. 

The Systolic Blood Pressure. (Fig. 4.) The sys- 
tolic pressure as indicated by the sphygmomanometer, rep- 



Systolic=i30 

Range=30 

Diastolic=ico 




M< 



US 



FiCx. 4. 

Fig. 4. Normal Pulse Tracing; showing relation of Systolic, 
Diastolic, Pulse Pressure C, and Mean. Pulse Pressure equals 30. 

resents the pressure within the vessels at the time of systole 
of the ventricles. 

The Diastolic Pressure. (Fig. 4.) The diastolic pres- 
sure represents the ebb to which the arterial pressure falls 
during cardiac diastole. 

The Pulse Pressure. Range or Amplitude 
(Klemper) (Fig. 4.). The arterial pulse is caused by varia- 
tions in pressure within the arterial system caused by the 
intermittent pumping action of the heart. The difference 
between systolic and diastolic pressure, i. e., the variation 
in pressure occurring- within the vessel during- a complete 
cardiac cyc 1 e, is termed the pulse pressure. This figure is 
obtained by subtracting the diastolic from the systolic pres- 
sure. The normal pulse pressure rouges between 20 and 
30 millimeters of mercury. 

Variations in the pulse pressure in the same individual 
constitute a most important part of the study of blood 
pressure. 

It is- theoretically possible that the pulse pressure should 
be influenced in at least three ways. 1 — An increase in the 
amount of blood delivered at each beat of the heart would 
tend to increase the difference between systolic and diastolic 
pressures. 



14 The Sphygmomanometer 



2 — A rapid emptying of the vessels, the cardiac output 
remaining the same, would tend to increase this difference. 
This would occur independently of whether the blood was 
passed onward into the capillaries or was regurgitated back 
into the ventricle. 

3 — Rigid vessel walls would influence pulse pressure. 
If the arteries were rigid tubes, the heart at each systole 
would be compelled to move the blood in the arterial system 
as a whole, while during diastole the flow would cease. 
There would thus be an increase of pressure during systole,, 
while during diastole it must fall almost to zero. 

The Mean Pressure. The mean blood pressure is 
valuable chiefly as an indication of the amount of strain to 
which the heart and larger vessels are subjected. It varies 
with the pulse pressure, the systolic pressure and the dia- 
stolic pressure. 

To obtain the mean pressure, divide the sum of the 
systolic and diastolic pressures by ■ two or add half of 
the pulse pressure to the diastolic pressure (see page 13). 

Pathologically, the pulse pressure increases in organic 
diseases of the kidneys, in arterio-sclerosis and in aortic 
insufficiency. It diminishes from other organic diseases of the 
heart, affecting the valves or myocardium. 4 It is noted that in 
the healthy the pulse pressure increases with moderate exer- 
tion, while every deficiency in the circulation shows itself by a 
reduction in the pulse pressure even when the systolic pres- 
sure is increased. This fact makes it possible to differentiate 
certain nervous disturbances of the heart from those of or- 
ganic origin. 

According to Gerhardt the systolic pressure in broken 
compensation may be high, but the pulse pressure always 
becomes small as the heart grows weak and becomes greater 
again when the power of the contraction is improved. 

THE PRINCIPLE OF THE SPHYGMOMANOMETER. 

Vital tissue is perfectly elastic. Therefore any pres- 
sure applied to the surface of the body will be directly 
transmitted to the underlying structures without loss of 
force. It is upon this principle that the indirect method of 
measuring the blood pressure is based. 



(i) Elehbers Jour. A. M. A. Sept. 19. 1908. 



The Sphygmomanometer 




A 

A. — Pressure in "b" 135 mm.Hg., pressure 
is therefore collapsed, pulse cannot pass. 



130 mm.Hg.. B 




B. — Fressure 
-passes. 



B 

V 129 mm.Hg., pressure in "a" 130 mm.Hg., pulse 



Fig. 5. 

Fig. 5. Diagram of Relations of Armlet to Brachial Artery. Ex- 
planation of, systolic reading: a, artery; b, compressing armlet; c, re- 
taining cuff; d, tube to manometer; e, humerus. 



[6 



The Sphygmomanometer 




A. — Systolic pressure in "a' 
mm.Hg., artery not compressed. 



130 mm.Hg., pressure in "b' 




B. — Diastolic pressure in "a" 100 mm.Hg. 
mm.Hg., artery collapsed. 



pressure in "b" 101 



Fig. 6. 

Fig. 6. Diagram of Relation of Armlet to Brachial Artery. Ex- 
planation of diastolic reading; a, artery; b. compressing armlet; c 
retaining cuff; d, tube to manometer; e, humerus. 



The Sphygmomanometer 17 



Pressure is applied to an accessible part of the body 
over a large blood vessel such as the brachial. If the amount 
•of this pressure is sufficient to overcome the pressure of the 
blood within the vessel, the vessel will be collapsed and the 
pulse prevented from passing- beyond it. If the amount 
of the compressing- force is measured and expressed in defi- 
nite terms of weight (as millimeters of a column of mer- 
•cury) then we can, by applying just sufficient pressure to 
collapse the vessel, measure the amount of force exerted 
by the blood in preventing this collapse. 

In practice the pressure is produced by a cautery bulb 
or a small hand pump, and applied to the arm by means of a 
hollow flat rubber bag. This is applied about the arm and 
held there by some form of inelastic cuff. Communication 
with a mercury manometer measures the amount of pres- 
sure applied to the vessel. 

Explanation of the Systolic Reading. 

Fig-ure 5, A and B, shows the relation of the com- 
pressing bag to the artery. In Figure A, the pressure with- 
in the cuff" is greater than the blood pressure within the 
artery, which is therefore collapsed and the pulse in the 
distal end of the vessel cut off. In Figure B, the pressure 
in the cuff, has been reduced so that it is a fraction of a 
millimeter less than the systolic pressure within the vessel. 
"Now at each systole a small amount of blood will pass the 
constriction and will reach the distal end of the artery, 
where the wave can be felt by the palpitating finger at the 
wrist. 

Explanation of the Diastolic Reading. 

Figure 6, A and B, represents the conditions existing 
between the constricting cuff and the vessel at the diastolic 
time of pressure. A represents a pressure within the cuff 
less than the sytolic ^pressure in the vessel. This is insuf- 
ficient to affect the vessel during the systolic period. B 
.-shows the artery and cuff during the diastolic period., when 



i8 



The Sphygmomanometer 



the pressure within the artery at its lowest point, a fraction 
of a millimeter less than the pressure within the cuff. Con- 
sequently the artery is collapsed at this time. The effect 
of each succeeding systole is to alternate between a round 
and a flat vessel at the point of compression. This affects 
the pressure of air within the cuff which is in turn trans- 
mitted to the mercury column of the manometer and be- 
comes visible in the rhythmic fluctuation of the column of 
mercury which is synchronous with the pulse beat. Since 
the fluctuation will reach a maximum at the time when the 




F.'S. 7. Type of Mercury Manometer employing a vertical tube: 
A, Mercury-containing base; B, Manometer tube; C. tube to armlet; 
D, tube to bellows; E, scale. 

pressure in the cuff is approximately equal to the diastolic 
pressure in the vessel, we are justified in considering the 
base of the manometer column at this time a measure of the 
diastolic pressure within the vessel. 

THE SPHYGMOMANOMETER, METHOD OF USING 
AND RECORDING FINDINGS. 

Since the recent general adoption of the blood pres- 
sure test, many forms of sphygmomanometer have been de- 



Tut: Sphygmomanometer 



i$ 



vised in an effort to produce a durable, accurate and port- 
able instrument. 

These instruments may be roughly divided into two 
classes. Those dependent upon the height of a fluid column 
for measuring the pressure, and those employing some form 
of spring or anaeroid chamber. 

Generally speaking, there are two types of mercury 
(fluid column) instrument. One of these employs a verti- 
cal tube into which the mercury column is forced from a 
large containing chamber in the base of the instrument. The 
pressure is measured in millimeters of mercury on an appro- 
priate scale attached to the vertical glass tube. (See Fig. 

7-) 

The other employs a glass tube (similar to that first 
used by Poiseuille) (see page 10) bent in the form of a "U" 
with the open ends up. This tube is partly filled with mer- 
cury and one end connected by means of suitable tubing 
with the compression part of the apparatus. The degree 
of pressure is measured upon a suitable scale placed be- 
tween the two limbs of the tube, the pressure being repre- 
sented by the difference in the height of the mercury in the 
two limbs of the "U" tube. (See Fig. 3.) 

Attempts to produce an instrument of pocket size 
which might easily be carried by the physician, led to the 
introduction of the spring types of instrument above re- 
ferred to. 

While these spring and anaeroid instruments have much 
to recommend them in the way of compactness and 
portability, unfortunately this feature is more than offset by 
their inaccuracy and the variability of the readings obtained 
with them. Variations amounting to more than 30 milli- 
meters of mercury have been noted in instruments of this 
type. 

This difficulty makes it necessary for users of them to 
frequently check and correct their instruments with a stan- 
dard mercury manometer. 

The sphygmomanometer bearing the author's name is 
modelled after the type of apparatus employing the "U M 
tube and is designed to overcome the many shortcomings 
of the earlier instruments and to furnish an instrument 
which is easy to use. difficult to get out of order, accurate 



The Si'iivciMOAj AN0M1-: 



and as light and portable as is compatible with exactness 
and strength. 

The mahogany case, which encloses the complete appar- 
atus, including the arm-band and pump ( See Fig. 8) measures 




Fig. 8. 

Faught Sphygmomanometer. Packed for transportation. 

4 x 4^2 x 16 inches and weighs 3 pounds 9 ounces. The 
lid is hinged at one end and when raised supports the working 
parts of the apparatus. A spring check allows the lid to be 
raised to a vertical position, where it is automatically held 
locked during the observation. 

The "U" tube is provided with a scale which has been 
arranged to give the reading directly in millimeters of 
mercury. 

A special and distinctive feature of the apparatus is the 
means of preventing loss of mercury from the manometer 
tube when the instrument is not in use. This is accom- 
plished by means of two small cocks placed at either ex- 
tremity of the "U" tube, and which are kept closed when 
the apparatus is not in use. 

By eliminating all detachable parts, the time required 
to make the reading is reduced to a minimum. The only 
preliminaries to the test being to lift the lid, open three 
cocks and attach two tubes to their respective nipples. 



v . i,M()M ANOM ETER 



DIRECTIONS FOR OPERATING THE SPHYGMOMANO- 
METER. (Fig. 9.) 

The patient should be in a comfortable position, and 
in a sitting" or reclining' posture. The instrument -should 
be upon a level surface within easy reach of the examiner. 




Fig. 



( !. 



A Inner Arm Bag. B Outer Arm Band. C Tube from Arm 
Band. D Nipple for tube from Arm Band. E Hand-Berows. F Nip- 
ple for Bellows Tube. G Millimeter Scale. H Manometer Tube. I 
Link-Brace and Lock. K Mercury Guard Cock. L Mercury Guard 
Cock. M Fressure Guard Cock. Ni Release Valve. 

The lid is then raised until it locks in a vertical position. 
If the tube from the hand hebows is not already connected 
to the nipple F it should be firmly attached to it. The two 
mercury guard cocks K and L at the ends of the "U" tube 
should be opened and the escape valve N tightly closed. 

The hollow rubber bag of the arm-band A should be 
firmly Avrapped around the bared arm of the patient and 
securely bound there by the leather cuff and straps B. (See 
Frontispiece.) The cuff should be applied snugly, but not 
with pressure, as it is not designed to compress the member, 
but only to restrain the inner rubber bag while pressure is 
applied to it. 

The tube from the arm-band C is attached firmly to the 
nipple D. The cock in the nipple F is opened. 



The S p i l yg m o m a nom eter 



J'his arrangement forms a continuous closed pneumatic 
system communicating freely with the manometer tube of 
the instrument. Now when pressure is raised in the arm- 
band by the hand bellows, the amount of force exerted is 
indicated by the rise of the right hand column in the mano- 
meter tube H, the height of which will be indicated on the 
scale G in millimeters of mercury. 

To Obtain the Systolic Reading. 

With one hand find the pulse at the wrist of the arm. 
to which the arm-band has been applied. The ringers should 
be in a comfortable position and under no circumstance 
should be moved during the observation. Care should 
also be observed that the pulse is not cut off by undue pres- 
sure of the palpitating fingers. 

While the pulse is thus under observation, the pressure 
in the apparatus is raised by means of the hand bellows or 
pump until the pressure within the constricting band is 
sufficient to prevent the impulse from reaching the wrist. 
When this is accomplished the cock in the nipp^ M is closed 
to eliminate the elastic pressure of the hand bellows. Now 
by a fraction of a turn in the valve N the pressure in the 
system is slowly released. During this part of the proced- 
ure, a close watch should be kept upon the height of the 
mercury column and for the return of the first pulse beat ac 
the wrist. The level of the mercury column at the instant 
that the pulse passes the compression-band will represent 
the systolic pressure of the pitient under observation. It 
is advisable to repeat this procedure a few times to check 
the correctness of the finding. 

To Obtain the Diastolic Pressure. 

This may be accomplished in two ways. Of these, the 
second, will be found very valuable in case of small arteries 
or when the tension is low. on which occasions the diastolic 
wave is not perceptible. 

First Method. This depends on the to-and-fro mo- 
tion imparted to the mercury in the "U" tube which occurs 
after the pressure has fallen below the svstolic point and is 
synchronous with the pulse beat. Having determined the 
systolic pressure again raise the pressure to a few millimeters 
above this point and immediately close the valve M. Now 
allow the pressure to fall very slowly by releasing the valve N. 



The Sphygmomanom eter 



23 



As the mercury falls below the systolic point it will be 
noted that it acquires a rhythmic motion corresponding in 
time to the pulse. This will be found to gradually increase 
in amplitude up to a certain point, after which it decreases 
and finally ceases before zero pressure is reached. During 
this gradual fall, the bases of the mercury column, when 
the mercury is making the greatest excursion, represents 
the diastolic pressure. 

Second Method. Raise the pressure within the 
apparatus to the systolic point, then, while keeping the 
•fingers in touch with the pulse, allow the mercury column 
to gradually fall as in the first method. It will then be 
noted that at first the pulse is very feeble and thready 
in character and continues so for a time, then as the pres- 
sure falls it will suddenly assume the full bounding character 
of the pulse of aortic regurgitation. At the moment when 
this change occurs the height of the mercury column will 
represent the diastolic pressure in millimeters of mercury. 
(For explanation of this phenomenon see page 17.) 

Cautions. To obtain accurate and reliable clinical data 
with the sphygmomanometer, it is important that some 
systematic technic be adhered to, and that all observations 
not only on the same patient, but in all cases be made under 
as nearly the same conditions as possible. Attention to 
such details will eliminate largely the errors arising from 
such factors as position of the patient, presence of fatigue 
or mental excitement, arm used for observation, etc. It is 
also important to note the apparatus used, the time of day, 
the pulse rate, the age and sex of the patient. These should 
all be recorded in a chart prepared for this purpose. 

The following printed form has been taken from the 
author's work on Laboratory Diagnosis, 5 which has been 
found useful in keeping records of blood pressure tests. 

Care should also be taken to see that the observation 
is not too prolonged, for the interruption of the circulation 
in the extremitv will, if continued, itself cause changes 
in pressure. 

(5) Essentials of Laboratory Diagnosis, F. A. Fansht. F. A. Davis Co. 1909. 



24 The Sphygmomanometer 



No single reading should be accepted when it is 
possible to make more than one. it is better to see the 

patient a number of times under varying conditions before 
deciding- what his Wood pressure is. 

BLOOD-PRESSURE DETERMINATIONS. 

Clinical Report. 



Appar 



atus | 



Width of Cuff cm. 

Part examined, 

Right, 

Left, 
Posture, 
Pulse Rate, 

Svstolic mm. Hg. after 10 Bending Movements, mm. Hj 

Diastolic mm. Hg. " " K " " 

Pulse Pressure mm. Hg. 

Mean Pressure mm. Hg. 

Remarks. 



Time of Day. A. M P. M. 

Date .' 

Examined bv 



CHAPTER III. 



THE NORMAL BLOOD PRESSURE. 

Experimental study and clinical observation have es- 
tablished within fairly well defined limits, the normal blood 
pressure in man, and also the extent of what may be termed 
the physiologic variation. That is. the extent to which 
the normal reading may be modified by age, sex, exercise, 
time of dav, altitude, posture and pulse rate. The imme- 
diate effects of alcohol and tobacco have also been de- 
termined. 

REPORTS OF DIFFERENT OBSERVERS ON BLOOD 
PRESSURE. 

The Normal Systolic Variation. 

Faure. Direct measurement, . no to i6omm.Hg. 

Albert. Direct measurement, ioo to 160 " 

V. Basch. Indirect measurement, ... .no to 150 " 

Bruce. Indirect measurement, ....... 100 to 130 " 

Graupier. Indirect measurement 115 to 125 " 

Jellinek. On 500 healthy soldiers, .... 100 to 150 " 

Sahli. High limit of health, 135 

Hansen. Indirect measurement 100 to 160 

Hansen. Mean average. . . . 137 " 

Gumprecht. Indirect measurement. ...120 to 140 

These figures represent the work of a number of care- 
ful observers, under diverse conditions, in different countries 
and with a variety of apparatus. They may, therefore, be 
taken to represent with a fair degree of accuracy the limits 
of the normal systolic variation. That thev are a little too 
wide must be conceded when it is remembered that they 
were obtained with different instruments and different 
widths of cuff. Omitting- the two single figures of Hansen 
and Sahli, the average of the remaining eight observers is 
from 106 to 146 millimeters of mercury. 



a6 The Sphygmomanometer 

In a limited series of observations by the author 
employing a 10 centimeter cuff upon a few healthy adults 
who may be taken to be fair examples of the average city 
dweller, the systolic variations did not extend beyond 115 to 
142 millimeters of mercury. (See page 31.) 

These observations were made under a great variety 
of conditions, including different times of day, before and 
after eating, and during digestion, exercise, brain work, 
and rest, and before and after the moderate use of alcohol 
and tobacco. 

From the foregoing it would seem safe for the present 
to adopt as the normal limits of systolic variation in young, 
healthy adults of 100 to 145 millimeters of mercury. 

Sex. It is generally accepted that the systolic pressure 
in women is lower than in men under the same circumstan- 
ces. Lauder Brunton 6 states that he has found the systolic 
pressure in women to be from 10. to 15 millimeters lower 
than in man. Other definite figures on this point are want- 
ing. The difference is at best of but little importance, since 
we recognize no one pressure as standard, our chief concern 
being the variations occurring in the same individual at 
different times, and under different conditions. 

Posture. The following series of observations were 
made upon 22 healthy medical students : 7 

IO CENTIMETER CUFF. PRESSURE IN MILLIMETERS 
OF MERCURY. 

Systolic Pressure and Pulse Rate. 

Systolic Stand- Sit- ~ Hiad Right Left 

Pressure img. ting. supine Down. Iatrral. Lateral 

Right arm 132.6 133.3 152.5 166.2 155.0 no.o 

Average 130.8 131.7 150.4 165.6 143.5 133-0 

Left arm 130.0 130.0 U8.3 165.0 T14.0 156.0 

Pulse rate 86 82 68.7 65.8 68.1 69.1 

Summary of observations upon the effect of posture 
upon the systolic and diastolic pressures. s 

Systolic and Diastolic Pressures. 

Standing. Sitting. Supine. Hhau Down. 

1 — Arm Systolic 84 90 94 100 

Diastolic 70 70 76 80 

2 — Arm Systolic 126 124 132 134 

Diastolic 1 10 no t 12 115 

(6) Lancet, October ]7. 1908. 

(7) O. Z. Stephens. Jour. A. M. A. Oct. 1, 1904. 

(8) Sandford. Jour. A. M. A. Feb. 15. 1908. 



The Sphygmomanometer 



From these observations the following conclusions can 
be drawn as to the effect of posture upon blood pressure, 
pulse pressure and pulse rate. 

(i) Posture affects both the systolic and diastolic 
blood pressure. 

{2) The blood pressure rises in the brachials from the 
standing to the head down posture in the following order : — 
Standing, sitting, left lateral, right lateral, supine and head 
down. 

(3) The pulse rate is decreased in the same order that 
the blood pressure is increased. 

(4) The increase in pressure is accompanied by an 
increase in heart strength. 

(5) The pulse pressure increases from the standing 
to the head down posture. 

(6) The decrease in pulse rate is a conservative act 
of nature to protect the heart itself and the central nervous 
system. 

(7) The average systolic pressure in the sitting pos- 
ture is normally a few millimeters above that of standing. 

Age. During the first years of life the systolic blood 
pressure varies from 75 to 90 millimeters of mercury. 9 

According to the observations of Lauder Brunton 10 
the maximum pressure in children from 8 to 14 years 
is 90 millimeters of mercury. In vouth between 15 
and 21 years, 100 to 115 or 120 mm.Hg. In adults 
between 21 and 65 years, the systolic pressure should be 
from 120 or 125 to 135 or 150 millimeters of mercury. 
Above 65 years it may still remain between 153 to 150, or 
owing to senile changes in the arterial system go up to 180 
or even higher. In women as a rule the pressure is from 
10 to 15 millimeters lower. In strong, athletic men the 
pressure is usually somewhat higher, about 10 or 15 milli- 
meters more than in men of ordinary physique. 

Blood Pressure in Children. According to W. L. 
Stowell, 11 the following is a summarv of our knowledge of 
the blood pressure in children : 

( 1) Blood pressure in the young is low in propor- 
tion to extreme youth. 

(9) Krehl. Clinical Path. 

(10) L,anct. Oct. 17, 1908. 

(11) Arch, of IVdiiit. Feb., 1908. 



28 The Sphygmomanometer 



(2) Its rise and fall are more quickly influenced by 
emotions than in adults. 

(3) Diseases of the nervous system give heightened 
pressure. 

(4) As a general rule blood pressure observations in 
children are of physiologic interest, but have little clinical 
value. 

Time of Day. In the early hours of sleep there 
is a decided fall in blood pressure which gradually rises 
toward morning. 12 The pressure will be found to ap- 
proximate the minimum in the early part of the day, 
approaching the maximum as the day passes. 

Digestion. Evidence bearing on the effect of normal 
ingestion of food and the act of digestion is not very 
abundant. It is generally believed that these cause a slight 
elevation of blood pressure lasting from one to three hour*. 
The effect of improper eating and disturbances in the di- 
gestive tract will he considered later. ( See page 31.) 

Altitude. The observations of Peters. 13 made at an al- 
titude of 6.000 feet, seem to show that height has an import- 
ant bearing on the height of blood pressure, his tables showing 
that blood pressure normally rises with increasing' altitude. 
He beHeves that this fact has a close bearing on the value of 
altitude in the treatment of pnlmonarv tuberculosis. The 
elevation in pressure occurring at high altitudes probab 1 y 
has much to do with the distressing effect of travel in 
high altitudes upon patients with defective cardio-vascular 
systems. 

Exercise. Muscular exertion raises temporarily the 
blood pressure. (See pa^e 38.) This rise becomes le^s 
marked as the individual becomes accustomed to perform- 
ing that particular act or acts. This gradual reduction in 
the susceptability of the vascular svstem is. one of the bene- 
ficial effects of training. 

When effort is prolonged but moderate the pressure- 
rises, but soon adjusts itself to a mean high level, on which 
any additional increase in effort produces no further rise. 14 

(12) Brush and Fairweather. Am. Jour, of Physiol. Vol. v. T>. 1??. 
OS) Li. Peters, Archives of Int. Med. Aug., 190S. 
Cj-Ti Eirhherg, loo. cit. 



The Sphygmomanometer -2) 



During exercise (in the healthy) the systolic and dia- 
stolic pressures tend to become more widely separated, i. e.« 
the pulse pressure becomes greater. 10 (See also page 40.) 

G. Weiss 16 believes that the blood pressure may be 
modified to such an extent by both exercise and emotion, 
that even a brief walk to the office may markedly affect the 
reading. This fact is important. By recognizing this we 
can readily appreciate the importance of enforcing a brief 
rest and a tranquil mind upon a patient who may have been 
walking briskly, or who is agitated by apprehension of the 
approaching examination, before applying the test. 

Passive movements, except those causing pressure upon 
the thorax or abdomen, can be prolonged without causing 
material rise in the blood pressure. 1 ' 

Emotion and Excitement (pain). In discussing the 
rise in blood pressure in relation to emotional factors, 
Norris 18 says that, "It is little realized by the profession how 
great an influence aberrance of blood supply may have upon 
the mood, mental poise, apathy and physical beneficence of 
an individual." On the other hand he notes that the effect 
of pain, fright and mental excitement in producing increas- 
ed tension must always be borne in mind when making 
blood pressure observations. 

According to G. Weiss (loc. cit.) the blood pressure 
may be modified to such an extent by exercise or emotion, 
that even a brief walk to the office, or apprehension of the 
procedure, or vaso-motor disturbance from prolonged pres- 
sure, or sensations of heat or cold, or other causes of vaso- 
constriction or vaso-dilatation, even in a single member, 
may modify deceptively the arterial pressure. 

The importance of the bearing of these modifying in- 
fluences must never be overlooked. The circumstances sur- 
rounding the test, the despatch with which it is carried out, 
and the proper understanding between patient and examiner 
must all be considered. Only by this means will the many 
deceptive influences be prevented and the accuracv of the 
reading be assured. - 



(15) Krehl. loc. cit. 

(16) Presse Medicale, 2, Sept., 1908. 

(17) Eichberg, loc. cit. 

<18) G. W. Norris. U. of P. Med. Bull., April, 1908. 



30 The Sphygmomanometer 



As bordering on the physiologic, by reason of their 
universal use, a brief consideration of the effect of alcohol 
and tobacco upon blood pressure will be considered here. 

ALCOHOL AND TOBACCO. 

It is important to have a dear conception of the im- 
mediate effect of a moderate use of alcohol and tobacco 
in order to appreciate the pathologic changes resulting from 
long continued use of these drugs. 

Alcohol. 

From clinical evidence it appears that the effect of a 
moderate amount of alcohol even when taken habitually, does 
not cause any marked influence upon the pressure level. On 
the other hand it seems equally evident that the continued 
employment of even moderate amounts of alcoholic drinks, 
plus over indulgence in eating and carelessness toward 
proper elimination, will eventually bring about changes in 
the circulation which show themselves in a permanent in- 
crease in blood pressure. 

In this connection Russell 19 reaches the following con- 
clusion : "We may consider it to be generally accepted that 
generous feeding and the free use of alcohol leads to a con- 
dition of the pulse which is termed 'High tension,' especial- 
ly if there is not daily a free evacuation of the bowels.'' 

Tobacco. 

H. A. Hare in a prize essay published about 20 years 
ago, reports a careful and critical study of the effect of 
nicotine upon blood pressure. . In this essay he concludes 
that a small amount of tobacco (smoking) in the normal 
person accustomed to its moderate use, causes a sedative 
action accompanied by a lowering of blood pressure, whi'e 
tobacco in excess causes a secondary rise in the pressure. 
This is in substance all that we know to-day, in spite of the 
improved methods of observation now at our disposal. 

More recent observations 20 conclude that the evi- 
dence at hand does not lend support to the theory that 
smoking is an etiologic factor in the production of arterio- 
sclerosis, at least in so far as the theory assumes injury to 
the vessels. 

(19) Wm. RusselJ. Arteriosclerosis. F.Vpfrtonns and Blood Pressure, 1908. 

(20) Bruce, Miller and Hooker, Am. Jour, of Physiol., April, 1909. 



The Sphygmomanometer 31 



The following- figures from some personal observations 
are also in accord with the bulk of records bearing on this 
point. 

These records were made immediately before and after 
smoking a. varying number of cigars at different times 
during the day. The figures given are the systolic reading., 
taken in the sitting position : 



Before smoking 


U8 


after 


1 cigar 


130 






(< 4 1 




I30 


a 


3 " 


138 






(( t . 




I40 


" 


1 " 


130 after 


2 


cigars 132 


it 




I 22 
128 


" 


1 " 

3 " 


122 
1 30 


4 


132 


" 




122 


I and dinner 


135 " 


5 


130 



120 after 5 cigars t 30 

125 " S " 128 . 

Il8 " 2 " 120 
130 " I " 124 

The safe and logical conclusion as to the effect of 
tobacco on a man accustomed to its use, is that it affects the 
pressure no more than those other stimuli which are the 
necessary consequence of civilized life. 

ALIMENTARY HYPERTENSION. 

It has long been recognized that certain conditions oi 
the circulatory system, accompanied by alterations in the 
character of the pulse, originate from disturbances in the 
digestive tract. 

This change usually shows itself in an increase of vascu- 
lar tension, due to a tightening up of the musculature of 
the arterial walls caused by a reflex emanating from the 
splanchnic area. (See page 8.) In a certain degree this is 
a normal reflex and its action is noted in the normal indi- 
vidual of proper habits of eating and elimination. When it 
becomes pathologic we find that there are added factors 
which cause this elevation in pressure to become excessive 
and to be prolonged. 

Individuals exhibiting this condition usually belong 
to one of two types-. One is seen in the person with florid 
face, bulky frame^and full, strong pulse. The other ma\ 
not show the evidences of excessive indulgence so plainly, 
but will be found to be subject to more or less frequent 
attacks of "biliousness" or "torpid liver." 



2,2 The Sphygmomanometer 



This inter-relation between the digestive process and 
elevated blood pressure has long formed the basis for treat- 
ment, which usually consists of free unloading of the di- 
gestive tract, together with a reduction in the amount and 
alteration in the variety of food and fluids taken. The sub- 
sidence of excessive pressure is usually prompt after such 
measures. 

This combination not infrequently forms the entering 
wedge which finally causes death from cardio-vascular renal 
disease or apoplexy. The rationale of this complex disturb- 
ance in the metabolic processes is complicated and requires 
careful consideration. 

According to the researches of Russell (loc. cit.) our 
knowledge of the pathology of the condition is as follows : 

During the process of digestion there is a normal re- 
flex arising in the splanchnic area and passing to the vaso- 
motor centers in the medulla, which leads to a general 
arterial contraction. This in normal degree may be termed 
the physiologic hypertension of digestion. In the patho- 
logic phase, two other factors are also operative. First, 
the absorption of excessive amounts of the nutritative 
products of digestion, and the absorption from the intestines 
of the products of proteid decomposition. 

The first of these is the direct result of over eating, 
coupled with an active digestion; thus more food is con- 
verted to the needs of the body than is required for its main- 
tenance, an increased load is placed upon the excretory 
organs, imperfect nitrogenous waste elimination ensues and 
a bilious attack is the inevitable result. 

In the production of the second factor, the colon group 
of bacilli act upon the undigested proteid in the intestinal 
canal, particularly in the large intestine, and set up putre- 
faction. This pathologic decomposition is further favored by 
imperfect evacuation of the bowel. The sluggishness of the 
intestinal canal allows greater time for the absorption of 
these products, which enter the circulation and act as direct 
irritants to the muscular coat of the arteries. 

These putrefactive products be 1 ong to the aromatic 
series and comprise chiefly the etherial sulphates of Indol. 
skatol and phenol. These are eliminated by the kidneys and 
appear in the urine as the aromatic su 1 phate salts of 
potassium. 



The Sphygmomanometer - 33 



The amount of these substances becomes therefore a 
measure of the amount of absorption of these putrefactive 
products, and an indication of the amount of disturbance in 
pressure dependent upon this cause. 

The symptoms and degree of discomfort occasioned by 
the absorption of these poisons varies within extraordinarily 
wide limits. Some persons are remarkably susceptible to 
their action; old persons seem to be more susceptible than 
the young and middle aged. In some instances the mani- 
festations of toxemia are so profound as to constitute a defi- 
nite idiosyncrasy. 

Alimentary hypertension is the result, therefore, of a 
normal abdomino-arterial reflex, made excessive by over- 
loading of the digestive tract and the absorption of toxic 
substances from the large intestine. 

This hypertension may be the first link in the chain 
leading to arterio-sclerosis, contracted kidney and apoplexy, 
particularly if the heart strength be maintained. 

This symptom group is often vaguely, for want of a 
better explanation, termed gouty, or suppressed gout. The 
mental repression, the physical lassitude, and bilious attack 
are all directly traceable to the hypertension, resulting from 
the conditions just described. 

Treatment directed to the underlying causes will cause 
the symptoms and the hypertension to disappear, and if we 
are able to modify the patient's dietary and habits, we may 
succeed in preventing a return of the old conditions as long 
zs the new regime is adhered to. 



CHAPTER IV. 
PATHOLOGIC VARIATIONS IN BLOOD PRESSURE. 

We have seen that the blood pressure is subject to con- 
tinual and uncertain variations, depending upon, more or less 
uncontrollable factors. Fortunately these fluctuations are 
all confined within a definite range which makes it possible to 
recognize them when these alterations have passed beyond 
the prescribed normal limits and have entered the range of 
the pathological. When studied in conjunction with other 
physical signs and subjective symptoms we are able to obtain 
valuable aid in differentiating certain diseased conditions, to^ 
detect the incidence of untoward complications, and to fol- 
low more intelligently the effect of treatment. 

For convenience in study we may appropriately divide 
pathologic alterations in blood pressure into pathologic 
high pressure and pathologic low pressure. 

PATHOLOGIC HIGH BLOOD PRESSURE. 

High pressure per se is not a disease but a phenomenon 
or symptom, which may accompany a great variety of 
diseased conditions, including diabetes, gout, syphilis, 
chronic lead poisoning, cardio- vascular renal disease, many 
anomalies of nutrition, etc. 

Alterations in blood pressure may be brought about by 
any agent capable of acting upon the muscular or nervous 
mechanism of the heart and blood vessels, or it may result 
from sudden changes in the volume of the blood, as in 
hemorrhage. 

Acute Asphyxia and. Acute Anemia of the brain 
(medullary centers) will powerfully stimulate the vaso- 
motors, causing constriction of the splanchnic area and a rise 
in blood pressure. 

Lead Colic affecting- the abdominal vessels is usually 
associated with high blood pressure, as is also the early 
stage of Peritonitis. 21 Pain, even when slight, as in 
pinching the skin, usually raises the systolic pressure. 

(21) Krehl. Clin. Path, page 11. 



The Sphygmomanometer - 35 



Continuous high pressure is seen in certain forms of 
nephritis. Thus in primary acute Bright's disease and m 
nephritis secondary to scarlet fever, there is practically 
always a marked rise in arterial pressure. A rise amounting 
to more than 50 mm.Hg. has been observed within 48 hours 
of the onset of an acute nephritis. 22 Elevated pressure is 
also found in beginning arteriosclerosis of the first part 
of the aorta and of the splanchnic vessels. 23 

In dealing with the elevation of pressure, which is tke 
result of the action of drugs or of toxic agents, it is im- 
portant to bear in mind that the amount of the substance and 
its concentration, its potency as well as the duration of its 
action will determine the amount of elevation, the duration 
and the permanence of the effect. 

Apart from a few specific conditions which are usually 
accompanied by a marked and usually permanent rise, the 
majority of the moderate elevations of systolic pressure 
result from the development of poisons or toxins within the 
body, from faulty or defective metabolism (see page 
31) or during the course of many infections. (See page 
49- ) 

PATHOLOGIC LOW PRESSURE, 

A pathologic depression in blood pressure may be caused 
by the depressing influence of circulating toxins acting 
either upon the heart blood vessels or controlling nervous 
mechanism or to sudden withdrawal of a large volume of 
blood from the circulation, as in hemorrhage, after vene- 
section, copious diaphoresis, diarrhoea, or in shock. 

The lowest blood pressure compatible with life has been 
reported by Neu to be from 40 to 45 millimeters of mercury 
and this only occurred with subnormal temperature in 
the moribund state. He has seen recovery after a fall in 
pressure as low as 50 millimeters. 

In general it may be said that lowered blood pressure 
is of little significance except after hemorrhage or during 
surgical shock. Here the great and sudden reduction in 
pressure may be sufficient to immediately endanger life. 

It is noted that a moderate and progressive fall in 

(22) Buttermann, Arch, of Klin. Med. vol. Ixxiv. p. 11. 
(22) Krehl. loc. cit. 



36 The Sphygmomanometer 



pressure occurs in most progressive and prolonged fevers, 
as in typhoid fever. When due to such a cause the depres- 
sion is rapidly overcome and disappears as convalescence 
is established. 

Widespread dilitation of the vessels and consequent 
lowering of blood pressure has been noted in the last stages 

of ARTERI0-SCLER0SIS. 24 

Arterial dilitation and lowering of blood pressure may 
result from general loss of arterial tone. Thus if the 
splanchnic vessels become widely dilated and filled with 
blood, the other arteries are insufficiently filled. (There is 
insufficient blood in the body to properly fill the arteries if 
they are all widely dilated (see page 4), the pulse becomes 
soft, the temperature falls and syncope finally ensues. 

Cr iles' exhaustive experiments 25 would seem to show 
that surgical shock is caused by exhaustion of the vaso- 
motor centers, which renders them unable to maintain the 
normal tone of the vessels, so that the pressure falls often to 
a point sufficient to endanger life. 



(24} Krehl. loc. clt 
(25j Blood PrfHSUi 



CHAPTER V. 



BLOOD PRESSURE IN DISEASES OF THE HEART. 
IN VALVULAR LESIONS. 

In the study of the valvular disease of the heart the 
results do not seem to have special bearing upon the primary 
condition (defective valve) except in cases of aortic re- 
gurgitation. This is in part due to the usual complicated 
nature of the condition, which often includes arterial and 
myocardial changes and involvent of the kidneys. 

The chief value of the sphygmomanometer in the study 
of heart conditions applies to the condition of the myo- 
cardium, to a demonstration of the effect of therapeutic 
measures, and as a guide in prognosis and in the general 
management of cases. With it we are able to determine 
with considerable accuracy the benefit derived from the 
drugs and other measures employed. In this we may guard 
against insufficient or improper treatment and also against 
the over use of these same measures by demonstrating the 
therapeutically efficient dose and the proper interval of its 
exhibition. 

AORTIC REGURGITATION. 

The blood pressure test may be sufficient to establish a 
diagnosis in pure aortic regurgitation, the great pulse 
pressure occurring in this condition being almost path- 
ognomonic. Referring to the physics of the circulation we 
find that in aortic regurgitation the left ventricle is called 
upon to deliver an abnormally large volume of blood into 
the aorta to supply the demands of the circulation. This 
is because the heart is required not only to furnish sufficient 
blood for the needs of the body, but must also inject into 
the aorta at each systole enough surplus to compensate for 
the regurgitation of a large volume of blood into the left 
ventricle during" diastole. The natural result of the sudden 
injection of this large amount of blood into the arterial 
system will be to cause a sudden and great rise in systoh • 



38 The Sphygmomanometer 

blood pressure (immediately succeeding systole, the blood 
disperses in two directions, forward through the capillaries 
and backward into the ventricle, producing the phenomenon 
of the water-hammer pulse). Thus the pressure rapidly 
falls and the diastolic pressure is abnormally low. The 
combined result of this high systolic and low diastolic 
pressure is a great pulse pressure. 

In the presence of moderate or high grade generalized 
arteriosclerosis this phenomenon is further accentuated be- 
cause of the lack of normal elasticity in the arterial system 
tends to reduce the diastolic pressure to zero. 

CHRONIC MYOCARDITIS. 

The sphygmomanometer is a most valuable means of 
detecting alterations in the musculature of the heart, or 
before the development of the usual physical signs. Myo 
cardial degeneration may be demonstrated by searching for 
evidence of slight irregularity in rhythm and force and by 
the use of the work test. 

1 — Irregularity of Force axd Rhythm. 

Alterations in the normal musculature of the heart 
causes a disturbance in the force and rhythm of the pulse. 
These changes when marked are easily discovered by the 
methods of palpitation and ausculation, but when slight are 
less easy of detection by the usual means. It is then that 
these variations may be intensified and so more easily de- 
tected by the sphygmomanometer. 

A study of the weak and thready pulse which appears 
at the wrist just after the pressure in the cuff has been re- 
duced slightly below the systolic pressure in the vessel 
will accentuate any slight differences in the strength 
and regularity of the impulses. When the pressure 
approaches the diastolic it will be noted in cases of 
defective myocardium that the fluctuation of the mercury 
column is irregular because of this irregularity in the force 
and volume of the pulse. 

2 — Work Test. 
Bending Movements. 26 In the application of this test 
it is important to have the conditions surrounding the ob- 



(26) Personal communication from Dr. Francis J. Dever. 



The Sphygmomanometer - 39 

servation as uniform in detail as possible. Care in this 
matter will eliminate accidental variations and possible 
error arising from adventitious causes which might other- 
wise invalidate the test. 

The following directions are suggested to insure 
accuracy and uniformity of the findings. 

Sufficient time should always elapse after any exertion, 
such as a long or rapid walk or after climbing a flight of 
stairs, to permit the circulatory system to regain its normal 
condition before applying the test. Mental excitement from 
any cause, such as other examinations of the patient or 
apprehension of the approaching test, should be eliminated 
as far as possible. The patient should be sitting at ease, 
avoiding positions that might cause muscular strain. The 
test .should be made with despatch, to prevent changes in 
pressure resulting from prolonged compression by the cuff. 
(See page 23.) The patient should be instructed carefully 
in the nature of the test and technic of the bending move- 
ments so that they can be correctly carried out without a 
number of unsuccessful attempts. Throughout the observa- 
tion the cuff should be allowed to remain on the arm, so 
that the second reading may he made without delay after the 
exercise. 

The patient should occupv the same position during the 
second observation as in the first. 

The Bending Movements. 

These are ten in number and should be made in rapid 
and regular succession. The patient should stand erect with 
the feet together and hands held high above head, palms 
forward and thumbs locked. The body is then flexed at 
the hips in an effort to make the fingers touch the toes 
without bending the knees. The patient then recovers. 
This movement should be carried out ten times vigorously 
in rapid succession and the second blood pressure test made 
immediately. 

Information Obtained by the Test. 
In the normal healthy individual, without myocardial 
or arterial disease, it will be found that if, for example, the 
systolic pressure be 130 before the exercise, it will 
rise to 135 or 140 millimeters, falling: again within two to 
four minutes to the original lev- el. This return to normal 



40 The Sphygmomanometer 

may be so rapid that the temporary rise will be missed if 
the second observation is not made without delay. 

If both the systolic and diastolic readings are taken, it 
will be noted that during this temporary rise in pressure the 
pulse pressure will also be greater. 

In the case of a weakened myocardium, this temporary 
rise in pressure will not occur; on the other hand there will 
be a distinct fall with a diminished pulse pressure, at the 
same time the pulse will frequently be found to have 
become irregular. 

Cautions. 

It is not advisable to apply this test to patients with 
excessively high blood pressure, in those of apoplectic 
tendency, or in those with high grade arteriosclerosis'. 
The test is unsafe in those with a systolic pressure of 200 
millimeters or over. In such cases there is danger of ocular 
or cerebral hemorrhage or acute dilitation of heart. 

The test will be difficult if not impossible of application 
in women unless all tight clothing is removed. 

Valvular disease is not necessarily a contra-indication 
to this test, as the condition of the myocardium seems to be 
the only important factor, except in aortic regurgitation 
with high pressure, so that the presence of valvular lesions 
need not detract from the value of the information obtained 
by this test. 

TACHYCARDIA. 

Some cases of tachycardia with demonstrable heart 
weakness may be the direct result of the hypotension. This 
is seen in advanced arterio-sclerosis, in shock and after large 
doses of alcohol, choral and veratrum viride, and as the 
result of the toxemias of typhoid fever and tuberculosis. 27 

ANGINA PECTORIS. 

Reports by Russell and others seem to indicate that 
there is not necessarily any elevation in pressure in the 
interval of attacks. The coincidence of generalized arterio- 
sclerosis, which is one of the causative factors in the pro- 
duction of this condition, will affect the pressure according 

(27) G. W. Norris, U. of P. Med. Bull., April, 1908. 



The Sphygmomanometer - 41 



to the location and extent of the arterial change. (See page 
29.) A rise occurs shortly before or coincident to the 
attack of pain, passing again when the pain ceases. 

It should not be forgotten that cases of undoubted 
angina pectoris will be encountered in which there can be 
demonstrated no elevation in pressure either in the interval 
or during the attack. 

It has been also shown that in certain cases accompanied 
by a constantly high blood pressure, the attacks may be les- 
sened in number and severity, or even prevented by pro- 
phylactic measures directed toward a reduction of the high 
pressure. 28 



(28) Russell, loc cit 



CHAPTER VI. 



CARDIO-VASCULAR RENAL DISEASE. 

Clinical experience has demonstrated that the con- 
ditions of arterio-sclerosis and chronic interstitial nephritis 
are with difficulty treated as separate and distinct conditions. 
Their corelation is so frequent that we have come to look 
upon the contracted kidney of chronic interstitial nephritis 
as but the terminal stage in arterio-sclerosis. 

In the study of these phenomena it is of the utmost 
importance to recognize that arterio-sclerosis per se need 
not and frequently does not imply a pathologic elevation in 
blood pressure. Cases have come under observation in 
which evidence of arterio-sclerosic change in the radials 
was most marked, yet the sphygmomanometer findings 
showed no evidence of hypertension — in one case hypoten- 
sion was found. . 

This variation from the usual conception of the state of 
the blood pressure in arterio-sclerosis is due to the fact that 
this condition does not always manifest itself as a general- 
ized change more or less evenly distributed throughout the 
arterial tree. Thus it is evident that a local arterio-sclerosis 
appearing in the radials (and it is by palpitation of the 
radials or other superficial vessels that a diagnosis is usually 
made) might not and probably would not be accompanied 
by any change in blood pressure. 

In arterio-sclerosis involving the aorta, the loss of 
elasticity in that vessel would tend to produce a moderate 
rise in pressure, while involvment of the splanchnic area in 
the arterio-sclerosis on account of their great area and their 
close relation in the maintenance of normal blood pressure 
would, without doubt, be accompanied by marked and 
permanent elevation in pressure, even when not accompanied 
by vascular disease in other quarters. 

The anatomic changes found in the kidneys is the 
result of interference in their nutrition incident to altera- 
tions in normal blood supply and normal blood pressure 



The S p h yg m o m a x o m e t e r 



This disturbance of kidney function occurring- in the course 
of arterio-sclerosis forms a link in a vicious circle which by 
adding to the already circulating toxins, tends to further 
elevate blood pressure. 

As the direct result of the heightened pressure general- 
ly found in cases of arterio-sclerosis the pulse is usually 
spoken of as ''high tension." "incompressible" or "hard." 
Associated with this we find the well-known urinary findings 
of chronic interstitial nephritis and usually an accentuated 
aortic second sound. 

Pathologic Anatomy. 
The change affecting the arteries is a permanent one 
and is the outcome of the combined action of circulating 
toxins and the continued high pressure. These consist of :~ 9 
i. — A marked thickening of the tunica media due to hyper- 
trophy of the muscular fibers. 2. — A thickening of the 
interna due to hypertrophy of the connective tissue. 
3. — In some cases, a distinct hyperplasia of the adventitia. 
Except in case of local arterio-sclerosis, these changes are 
found quite evenly distributed throughout the arterial 
system in the cerebral, coronary and renal vessels, for 
example. 29 

Mode of Production of Arterio-Sclerosis. 
As a result of auto-intoxications from over-eating or 
from syphilis, lead poisoning, etc., there occurs in the circu- 
lating blood certain toxic substances or "muscular excit- 
ants," as they are termed by Huchard. These by their 
irritating nature stimulate the arteries to hypertonic con- 
traction, and a narrowing of the blood vessels, particularly 
the smaller arteries and arterioles. This general narrowing 
of the blood path produces an elevation in b 1 ood pressure, 
so that palpation and tests with the sphygmomanometer 
show distinct evidence of this change. If these mus- 
cular excitants are continuously present the hypertonus 
and elevated blood pressure will be continuous, and the 
amount of the former determines the amount of the latter. 
If this vascular hyper-contraction last a sufficiently long 
time, it induces primary and secondary changes in the 
vessel walls, which continues and further augments the 

(29) Russell, loc. cit 



44 The Sphygmomanometer 

effect upon blood pressure. In advanced cases this ele- 
vation of pressure may amount to from 200 to 250 per 
cent, above the normal. This great and continuous eleva- 
tion occurs in no other pathologic condition, which does 
not include the complication or terminals of arterio-scler- 
csis, except possible aortic regurgitation and here it is dif- 
ficult to rule out arterio-sclerosis on account of frequent 
coincidence of this disease. 

The sphygmomanometer is of great value in studying 
the conditions of the circulation in cardio-vascular renal 
disease, particularly in the early stages, when it often 
furnishes the warning of grave danger. Often the individual 
is unaware that he has departed in any way from the normal. 
High pressure accompanied by small amounts of albumen 
and the occasional appearance of casts, is strong evidence in 
favor of permanent kidney change. In cases presenting' 
only slight or no alteration in the normal blood pressure, 
but with a suspicion of chronic nephritis, it will be necessary 
before establishing a diagnosis to eliminate the deceptive 
conditions which may be due to constipation and auto-intoxi- 
cations. (See page 31.) 

In the absence of any definite physical sig)is which 
point to kidney involvmcnt, but with a continuously 
elevated blood pressure, which cannot be otherwise ac- 
counted for. we are justified in strongly suspecting chronic 
in tcrstitial n ephritis. 

In the average case of moderate duration the blood 
pressure readings will range between 160 and 290 mm.Hg. 
or even higher. The height of the pressure will be prac- 
tically continuous except for minor fluctuations caused bv 
constipation, auto-toxemias and the usual phvsiologic 
factors. (See page 26.) 

In primary acute Bright's disease occurring in the 
course of scarlet fever there is practically always a sudden 
and marked rise in pressure. Buttermann 30 has noted a 
rise of as much as 50 mm. He. occurring in 48 hours after 
the onset of an acute nephritis. In advanced nephritis the 
detection of further sudden elevations will indicate the 
urgent necessity for immediate reduction in pressure to pro- 



(30) Archl. f. klin. Med. vol. lxxiv. p. I. 



The Sph yg m o m a n o m eter 



tect the cerebral vessels from rupture or the occurrence of 
oedema of the brain and coma. 

UREMIC DISTURBANCES. 

The routine use of the sphygmomanometer in all cases 
of nephritis is as important as the routine examination of 
the urine. Approaching uremic crisis are usually indicated 
by a sudden and marked rise in pressure often before they 
become evident in any other way. 31 In cases of contracted 
kidney a sudden fall in pressure indicates the giving out of 
the heart. 

In the sphygmomanometer we have a practical and ac- 
curate means, not only of assisting materially in the diag- 
nosis of cardio-vascular renal disease, but by furnishing 
early warning of impending dang-er we are enabled to 
institute prophylactic treatment. 

CEREBRAL HEMORRHAGE. 

In the majority of cases of cerebral hemorrhage we 
have to deal with cardio-vascular renal disease in which the 
involvment of the cerebral vessels is but an incident 
(usually terminal) in the general arterio-sclerosis change. 
Recognizing this intimate relation between these conditions 
it seems almost unnecessary to note that the control of the 
high pressure is the most essential feature in the manage- 
ment of cases with an apopletic tendency. 

The sphygmomanometer furnishes the evidence which 
•calls for appropriate preventative treatment, the success of 
which may be followed from time to time by noting its 
effect upon blood pressure. 

From a study of 16 cases of cerebral hemorrhage by 
C. W. Sawyer, 32 the following conclusions were arrived at : 

i. — Patients with kidney lesions which will not respond 
to treatment or whose blood pressure will not lessen are 
liable to fatal attacks of uremia. 

2. — Nephritic patients with increasing blood pressure 
are especially liable to cerebral hemorrhage. 

3. — A second hemorrhage, with a hemiplegia due to 
hemorrhage already existing, but with no kidney lesion, is 
usually fatal. 



(31) H. Engel, Berlin, Kiln. Woehen, Oct. 22, 1908. 
•(32) Ohio State Med. Jour. Nov., 1908. 



46 The Sphygmomanometer 

4. — Patients with nephritis and increased blood pres- 
sure are as likely to succumb to a second hemorrhage as- 
live. 

OCULAR HEMORRHAGE. 

Fox and Batroff 33 report in detail a study of one hun- 
dred consecutive cases of ocular hemorrhage in which the 
blood pressure test was employed. 

In 80 per cent, of these cases hypertension was en- 
countered. In 40 per cent, of the cases of retinal hemor- 
rhage were accompanied by chronic interstitial nephritis. 
Arterio-sclerosis was present also in zj per cent, and 
parenchymatous nephritis in 13 per cent. 

These authors are convinced that increased arterial 
tension are an important factor in the causation of other 
ocular conditions, as acute glaucoma. 

In the series of 100 cases j$ were cases of retinal hem- 
orrhage. The average pressure for the series was above 160 
mm.Hg. The highest recorded being 265 in a case of inter- 
stitial nephritis showing albumen and casts. 26 cases had a 
pressure above 200 mm.Hg. 26 were between 150 and 200 
and 18 below 150. Thus 66 of the cases showing the direct 
effect of the e^vated blood pressure (ocular hemorrhage) 
all showed arterial or kidney degeneration and a large pro 
portion showed a distinctly pathologic elevation of blood 
pressure. '' ■ 

Further discussion seems unnecessary to emphasize the 
importance of the evidence furnished by the blood pressure 
test. It is invaluable in corroborating suspicions and con- 
firming diagnosis, and by the early detection of elevated 
pressure, giving the patient a better chance of prolonging 
life and preserving sight by the institution of proper and 
adequate treatment. 

EXOPHTHALMIC GOITRE. 

Norris 34 notes that instability of the blood pressure in 
wdiich there occurs frequent and irregular alterations be- 
tween normal and hyper- and hypotension occurs notably in 
exophthalmic goitre. This condition has also been re- 
ported by L. F. Baker. 35 These alterations, particularly 



(33) Colorado Medicine, Maj% 1909. 

(34) G. W. Norris, loc cit. 

(35) Jour. A. M. A., Oct. 12, 1907. 



The Sphygmomanometer 4? 

toward hypotension may be related to the tachycardia found 
in this disease either as cause or effect. 

ECLAMPSIA. 

As might be supposed from the clinical manifestations 
of eclampsia and its evident relation to altered metabolism, 
particularly of the kidney, the retention of the waste pro- 
ducts of metabolism and probably the development of 
specific toxins, the blood pressure is uniformly and marked- 
ly e 1 evated. 

Routine blood pressure observations should be made 
a part of the periodic examination of pregnant women, the 
intervals between the tests becoming shorter as the period 
of gestation advances; nor should the test be omitted 
during the puerperium, as the danger from eclampsia does 
not terminate with the evacuation of the uterus. 

According to G. S. C. Badger 36 the blood pressure is 
always high after the onset of the condition, when it be- 
comes of prognostic importance. For, if in spite of im- 
provement in the subjective symptoms and an increase in 
the quantity of urine the pressure remains high, then the 
prognosis is grave and labor should be induced without 
delay. After emptying the uterus if the pressure remains 
high the prognosis is grave as to complete recovery. 

R. C. Davis 3, has found an increase in pressure in all 
cases of eclampsia coming under his observation. In the 
treatment of such cases a coincident reduction in the amount 
of albumen in the urine is noted with the reduction in blood 
pressure. 

In his experience the most successful method of treat- 
ment has been the employment of blood pressure reducers 
and toxin eliminators, foremost among them being the hot 
pack and vapor bath. 

DIABETES. 

Arthur B. Elliott 3S reports a series of 150 observations 
upon 25 diabetics of all ages. He found the diastolic pres- 
sure hard to obtain. The cases, complicated with cardio- 
vascular renal disease, represented 20 per cent, of the 25 
cases reported. In these the systolic pressure was marked- 

(36) Boston Med. and Surg. Jour.. May 9, 190S. 
(27) U. of P. Med. Bull., May. 1908. 
(38) Jour. A. M. A., July 6, 1907. 



S The Sphygmomanometer 



ly higher than in the cases not so complicated. Hypo- 
tension seems more prone to develop in cases showing acid 
intoxication. Diabetes per se does not seem to have any 
marked effect upon the blood pressure level. Cases show- 
ing more than three per cent, of sugar showed a slightly 
greater tendency toward the subnormal than those showing 
less than this amount. 

Summary of Systolic Pressure Records. 

Number of cases 25 

Average age 45 years. 

Male 13 

Female 12 

Average weight 156 pounds 

Average systolic blood-pressure 127 mm.Hg. 

Average of cases showing 3 per cent, sugar 121 mm.Hg. 

Showing less than 3 per cent, sugar, pressure average . . 135 mm.Hg. 

Number of cases developing acid intoxication 10 

Average systolic pressure 107 mm.Hg. 

Number of cases not showing acid intoxication 15 

Average systolic pressure ' 140 mm.Hg. 

Number of cases, showing indication of arterio-sclerosis 

and kidney involvement 5 

Average systolic pressure 164 mm.Hg. 



CHAPTER VII. 

INFECTIOUS DISEASES. 
SCARLET FEVER. 

The blood pressure shows a moderate rise at the onset 
of the disease and thereafter follows closely the pulse and 
temperature curve. After the seventh or eighth day the 
pressure ma}' be below normal. Complications have a 
marked effect upon blood pressure. Cases showing 
albumenuria generally show hypertension. This rise in 
pressure is accompanied by slowing of the heart's action. 
(See page 35.) With the subsidence of the kidney irrita- 
tion the pulse rate increases and the blood pressure returns 
to normal. 39 

DIPHTHERIA. 

The pressure is generally lowered during the active 
stage of this disease, the amount depending largely upon 
the degree of toxemia. The administration of strychnine 
and alcohol annul this fall only when given regularly. The 
.-administration of antitoxin, while usually causing a brief 
rise in temperature, has no effect upon the blood pressure. 39 

TYPHOID FEVER. 

Here the blood pressure is usually considerably lowered, 
the hypotension increasing with the duration of the disease 
-and gradually disappearing with the establishment of con- 
valescence. It may be abruptly terminated by the inter- 
currance of complications, such as pneumonia or peritonitis. 
Large or repeated hemorrhage will, of course, tend to 
produce a fall in pressure. 

ACUTE INFECTIONS. 

In general have but little if any effect upon blood 
pressure. In many there may be a slight fall during the 
height of the invasion, which rapidly subsides as the infe:- 
t : on is overcome. 

*39) J. Davidson, lancet. Oct. 19, 1907. 



50 The Sphygmomanometer 



MISCELLANEOUS CONDITIONS. 

Neurasthenia. 

As might be expected from the character of the con- 
dition, considerable irregular variation will be found in the 
reading in this condition, due in all probability to the general 
instability of the nervous system which is unable to exercise 
proper control over the blood pressure regulating mechan- 
ism. The reading may be higher than normal, but usually 
lower: Treatment, when successful, may leave the patient 
with a different normal level from that existing before treat- 
ment was begun. 40 

In differential diagnosis between true neurasthenia re- 
sulting from exhaustion of the nerve centers and its ac- 
companying low pressure, from a similar symptom complex 
due to the absorption of toxins from the digestive tube and 
in which the blood pressure is high, the blood pressure test 
is invaluable. 41 Obviously such a differentiation is absolutely 
essential since the treatment of the two conditions are 
diametrically opposite. 

Polycythemia. 

There has as vet been found no definite relation between 
the high blood pressure and an increase in the number of 
red corpuscles. Moller 42 examined 25 apparently normal 
individuals with high blood pressure and in two only did 
he find an unusually large number of red corpuscles. 

In lead colic and in beginning peritonitis, statistics- 
show that there is generally an elevation in blood pressure. 

In cholera the rapid reduction in the volume of blood 
incident to the diarrhoea causes a marked reduction in the 
blood pressure. 

At the menopause the same instability in the pressure 
as noted in exophthalmic goitre is encountered. 

(40) E. D. Macnamara. Lancet. July 18, 1908. 

(41) L. Williams. Clinical Jour.. London, Jan. 8, 190* 

(42) Deuteh. Med.. Wochen.. Oct. 28, 190S. 



CHAPTER VIII. 



THERAPEUTICS. 

The study of blood pressure frequently furnishes the 
key to proper treatment in a number of diseases; it also 
furnishes a reliable guide as to the efficiency of the resources 
employed, as well as the time during which treatment should 
be continued. 

It is not within the scope of this little work to more 
than touch upon a few of the most important points in the 
relation of blood pressure to the management of disease. 

The general symptoms accompanying diminished blood 
pressure indicate in no uncertain manner the necessity of 
tonic treatment. In cases of emergency with suddenly fall- 
ing pressure and evidence of collapse, adrenalin intravenous- 
ly or hypodermatically is indicated. 

For the sudden drop in blood pressure occurring in ad- 
vanced arterio-sclerosis, digitalis is indicated, provided there 
is no evidence of marked myocardial degeneration, in which 
event strychnine is the safer drug to use. 

In lowered blood pressure from hemorrhage or profuse 
and prolonged diarrhoea the pressure is the best indicator of 
the amount and the frequency for the use of saline infusion 
or the Murphy treatment. 

Albumen appears in the urine whenever the kidneys are 
passively congested and its importance, when due to this 
cause, is often greatly exaggerated. Albuminuria associ- 
ated with kidney disease is nearly always accompanied with 
elevation in blood pressure; albumen when due to other 
causes is not usually so accompanied. 43 As these two causes 
of albnmenuria demand almost diametrically opposite treat- 
ment, their differentiation is of the utmost importance. 

A similar differentiation is necessary in the separation 
of true neurasthenia, caused by exhaustion of the nerve 
centers, accompanied by low pressure from a corresponding 
symptom complex due to absorption of toxins from the di- 
gestive tube, and in which the Wood pressure is high (see 
page 50). 



52 The Sphygmomanometer 

Post-influenzal conditions demand a similar differentia- 
tion. In the lowered pressures stimulating, tonic and hyper- 
nutrient treatment is demanded, wmle in tne nign tension 
cases relaxation, sedation and limited feeding is indicated. 
Failure to make this distinction may Le traught with 
disaster. 44 

High pressure in the apoplectica.lv inclined calls for 
active and continued pressure reducing treatment. Among 
the drugs winch are generally depended to accompisn tins 
change are the nitrites, of which a freshly prepared solution 
of sodium nitrite will be found the most serviceable, being 
easy of administration and prolonged in action. 

In the treatment of aortic aneurism with high pressure, 
the use of hood pressure reducing agents may materially 
prolong life by reducing tne tendency to rupture and at tne 
same time afford relief from the most distressing symptom — 
pain, by lessening the tension in the aneunsmal sac. thereby 
relieving" the nerve irritation and the pressure upon sur- 
rounding organs or tissues. In one case of this character, 
occurring recently in the service of Dr. Judson Daland, the 
patient was relieved promptly and almost completely, while 
hemoptesis was checked by the administration of sodium 
nitrite, given prior to the operation of wiring the sac. Dur- 
ing the introduction of the wire, which was done by the aid 
of local anesthesia, a close observation of the blood pressure 
enabled a minimum pressure to be maintained, thereby 
greatly reducing the chances of sudden rupture of the sac, 
and by reducing the force of the circulation favoring the 
formation of a clot. 

In acute Brights, after failing to reduce the pressure 
by the usual measures, it may sometimes be controlled by the 
electric light sweat bath. In one case a reduction of from 
20 to 40 millimeters was obtained, the beneficial effects last- 
ing for many hours, so that regular observation of the pres- 
sure determined the proper interval between the sweats. 

By a regular blood pressure observation we may de- 
termine the maximum efficient dose of many cardiac 
remedies, and to follow their action with greater accuracy 
than by the usual physical measures. 

After all the value of the usual drugs which have been 



<44) L. Will 



The Sphygmomanometer • 5j 



supposed to effect blood pressure has been disappointing" in 
the light of the blood pressure test, even the nitrites and 
potass um iodide being very uncertain in action, often failing 
to have, any effect when most needed. 

A. E. Mills 45 after careful and critical tests, reaches 
the same conclusion and suggests the use of opium or its 
derivative morphia, which he asserts is of particular 
value in arterio-sclerosis with high pressure. He cites two 
cases of arterio-sclerosis with granular kidney in which the 
dyspnoeic symptoms and the high pressure were promptly 
relieved by the hypodermic administration of morphine. 
The blood pressure in one case falling" from 220 to T78 
millimeters within an hour, and in the other from 200 to 
170 in less than half an hour. In the first case a quarter 
grain of morphia was given, followed at intervals of fifteen 
minutes by two-eighths. 

In cases of arterio-sclerosis, Lauder Brunton 46 recom- 
mends trying sodium iodide, ten grams a day. for a long 
time, also ammonium and sodium hippurate. sodium benzo- 
ate. sodium nitrite or potassium bicarbonate. 

When the heart begins to fail with irregularity and 
intermissions in the pulse, dizziness, inabih'tv of exertion. 
dyspnoea and oedema of the ankles, a combination of 
card ; ac tonics with vaso-dilators is indicated; the diet and 
drink is to be restricted and rest comparative or absolute 
enjoined. Flatulent distention in these cases is often re- 
lieved by the following mixture : 

Rx. 

Liquor trinitrinis, m. ss. to hi. 

Spts. amnion, aromatic, m. xv. to lx. 
Spts. chloroformi. oz. 
Spts. aeth. comp., m. v. to x. 
Tinct. card. comp.. m. x. to xxx. 
Aq. meth. yiridi, qs. oz. 1. 
Mise. 

Sig. This draught to be repeated every fifteen minutes 
until relieved or until the trinitrin causes dizziness. Inhala- 
tions of chloroform, ethyl idodide. or subcutaneous injec- 
tions of morphine may be necessary. 

(45» Australasian Medical Gazette. Jan., }'.?*. 
M6) Lauder Brunton. Ice. rit. 



54 



The Sphygmomanometer 



DIET IN CARIO-VASCULAR RENAL DISEASE WITH 
HIGH PRESSURE. 

Proteid food, particularly meat, should be limited and 
the diet composed chiefly of bread, vegetables, fruit, butter, 
milk and fat bacon. 

Alcohol, tea, coffee and tobacco should be taken sparing- 
ly if at all. Little fluid should be taken with meals; plain 
-water, hot water or mineral water, hot or cold, may be taken 
freely about three hours after eating. 

Moderate exercise without strain is beneficial, but 
strain either mental or physical must be absolutely avoided. 
Light mental work in moderation is good, but irritation and 
emotional disturbances are bad. 

Constipation must carefully be avoided. 



CHAPTER IX. 



IN SURGERY. 

The sphygmomanometer has many applications in 
surgery. The safety of anesthesia is increased by the fre- 
quent application of this test during all prolonged operations. 
By it an impending shock is easily detected, often be- 
fore the usual signs develop. Thus regular and frequent 
tests of the blood pressure, before, during and after opera- 
tions, will serve to indicate the need for stimulation, etc. 

As an indication for venesection, saline infusion or the 
Murphy treatment, and as a guide to the beneficial effect of 
these several measures, the sphygmomanometer is pre- 
eminent. 

A few observations have been reported where the use of 
the blood- pressure test has been of great value in certain 
surgical conditions. As in wiring aneurism, in operations 
upon cases suffering from shock, in eye surgery and in oper- 
ations involving the pleurae. 

In the case of aortic aneurism above referred to (page 
$2) the patient was prepared for operation by the pre- 
liminary administration of sodium nitrite until no further 
effect upon blood pressure could be obtained. During the 
process of wiring constant observation of the blood pressure 
indicated with great certainty the need for further nitrite 
and for the administration of stimulants. 

In direct transfusion the test made upon both the 
patient and the donor furnishes a reliable guide of the 
safe length of the operation. 

In eye surgery the following reference from L. Web- 
ster Fox is significant and suggests great possibilities for 
the test in the treatment of eye conditions associated with 
hypertension : 47 "It was interesting to note that in one case 
of acute glaucoma where the blood pressure was 265 
mm.Hg., 20 ounces of blood taken from the right arm 
when the pressure fell to 150 mm.Hg. This patient had an 
attack of acute glaucoma in the right eye two years before. 

(4 7) Ii. Webster Fox, !oe. cit. 



56 The Sphygmomanometer 

An iredectomy was performed by a skilled operator, but it 
was not successful. The blood pressure was evidently so 
high that the eye was lost by an immediate intra-ocular 
hemorrhage and collapse of the eyeball. When the patient 
came under my care for a similar attack in the left eye 
there was tension of plus three and more and vision was 
gone for two days. I concluded that a reduction of tension 
in the eyeball must be obtained somehow before a successful 
iredectomy could be performed. Eserine failed to make 
any impression upon the dilated pupil or the tension within 
the eyeball. It was interesting to note the condition of 
the pupil after ten ounces had been withdrawn from the 
arm: it had commenced to contract and by the time that 
20 ounces were taken the tension (pressure) fell to 150 
mm.Hg, the pupil contracted to a pinhole and the tension in 
the eye was about normal. I was able to perform the 
iredectomy without untoward result and useful vision fol- 
lowed." While this is but an isolated case it serves to show 
very beautifully what may be done by an intelligent ap- 
preciat'cn of the effects of heightened blood pressure and 
what measures may be employed for its successful reduction. 
Capps and Lewis 48 arrive at one very significant 
and instructive conclusion in regard to the relation of certain 
vaso-motor reflexes and surgical procedures involving the 
chest. 

They note that following aspirations of pleural ef- 
fusions there frequently occurs a marked fall in blood 
pressure accompanied by unfavorable symptoms. They con- 
cluded that these could not be entirely accounted for by the 
changes occurring in intra-thoracic pressures, and that the 
effects were due to the operation of two types of reflex, one 
cardio-inhibitorv and the other vaso-dilator ; the latter 
simulating shock may be so profound as to be fatal. These 
reflexes are very prone to occur during operative procedures 
upon inflamed pleurae. 

For emergency in the treatment of this condition 
adrenalin intra-venously is indicated. Atropine is of little 
value and may even do harm. 

They suggest the foPowine: precautions as preventative 
measures : The instruments used should be allowed to irritate 

(4S .1. A. Capps and I>. Lewis. Am. Jour. Med Rci., Dpc. 1<»0S. 



The Sphygmomanometer • 57 



the pleura as little as is absolutely necessary : the projection 
of long drainage tubes within the pleural cavity is par- 
ticularly to be avoided ; swabbing the pleural surfaces is 
dangerous and to be condemned. 

Finally they emphasize the importance of taking the 
blood pressure test before and after all operations on the 
pleural cavity in order to foresee and thereby prevent the 
development of these dangerous blood pressure reducing 
reflexes. 



CHAPTER X 



LIFE INSURANCE EXAMINATIONS. 

The sphygmomanometer is an invaluable aid in the ex- 
amination of applicants for life insurance, particularly those 
above 35 or 40 years. 

A general knowledge of the subject of blood pressure 
should be required of every insurance examiner, who should 
be particularly familiar with the relation of blood pressure 
to those conditions most likely to be met with in the appli- 
cant for life insurance. These are chiefly those of the 
cardio-vascular system and kidneys. (See page 42.) 

A very important reason for the general adoption of 
the blood pressure test in life insurance is the fact that even 
the most experienced clinicians find it very difficult, if not 
impossible, to accurately estimate blood pressure by palpita- 
tion of the radial. To quote again from William Russe 1 l 49 
we find the following a very significant statement : "I 
must, however, again add a warning note to the effect 
that . . . . feeling the radial is not always a reli- 
able guide as to what the bracial pressure will read 
. . . . I have two such cases under observation as I 
write this ; the radial artery in neither being hard or incom- 
pressible and yet in both there is a steady reading of over 
200 mm.Hg." 

From the evidence found in the statistics of life insur- 
ance companies it is plain that this test is of greatest 
-value in just those conditions which show a high and in- 
creasing mortality. In one company the deaths from apo- 
plexy, nephritis and organic heart disease amounted to 25.1 
per cent, of all the deaths occurring during the past nine 
years. The percentage of deaths from apoplexy have in- 
creased from 7.0 per cent, in 1900 to 9.5 per cent, in 1908. 
Organic heart disease has advanced from 8.6 per cent, in 
1900 to 9.3 per cent, in 1908. Nephritis (chronic) remains 
about the same. 



f-49) W. Russell, loc. Ht., page 75 



The Sphycmom anometkk 59 



It is even more difficult to fix hard and fast rules for 
ihe guidance of the insurance examiner than it is for the 
clinician, because of the frequent mental perturbation in 
applicants. This difficulty may frequently be abrogated by 
repeated examination, which allows the applicant to become 
more familiar with and hence less disturbed by the exam- 
ination. 

In a number of personal communications received by 
the author from some of the large life insurance companies 
in the United States and Canada, it was a significant fact 
that with but few exceptions all the companies advocated 
the use of the sphygmomanometer in selected, if not in a 1 ! 
cases. When any discrimination was made it was suggested 
that the test would be of greatest value in cases of suspected 
high tension where there was any suspicion of heart or 
"kidney disease in applicants with a history of albuminuria 
or casts or in those subjected to severe or prolonged mental 
or physical strain, particularly if they had passed to 40- 
year mark. It would seem also to be indicated in over- 
weights, because of the apparent susceptibility of such indi- 
viduals to the causes of hypertension and the frequency of 
the occurrence of cardio-vascular renal d'sease in them. 



PERMISSIBLE VARIATION. 

Until more definite information accrues the limits laid 
-down by clinical experience must be adhered to, bearing 
constantly in mind the modifying effect of age. (See 
page 25. ) For example it would be unsafe to accept a man 
of 28 years with a constant pressure of more than 140 milli- 
meters, unless the cause of the hypertension was explained, 
while the same pressure in a case over forty years would 
be looked upon with less mistrust. 

The great frequency of the relation of alimentary 
hypertension makes it important to search for it and it is 
inadvisable to jump to the conclusion that all cases showing 
hypertension, particularly when occurring in young adults, 
is evidence of cardio-vascular renal disease. Careful search 
for confirmatory evidence should not be neglected before the 
risk is rated. 



6o The Sphygmomanometer 



HIGH PRESSURE AND TRANSCIENT ALBUMINURA. 

Probably the most confusing combination of symptoms 
met is the case which presents a slight hypertension and an 
Occasional trace of albumen in the urine. These cases are 
best examined at the home or branch office and should be 
referred there whenever possible, for it is often only after 
the most careful and complete examination with repeated 
urine and blood pressure tests that a correct conclusion re- 
garding the safety of the applicant can be reached. 

If after eliminating the possibiHty of an alimentary 
hypertension a distinct elevation in pressure remains with 
albumen in the urine, even in occasional and minute traces, 
the risk is doubtfully good, wliTe if accompanied by ac- 
centuation of the aortic second sound or casts the risk is 
bad and calls for rejection. 



INDEX. 



Alcohol 30 

effect on blood pressure 30 

Aliamentary hypertension 31 

in dol in 3 j 

reflex action in 32 

skatol in 33 

symptoms of ^ 

treatment of ^3 

types showing 31 

Angina pectoris 40 

Aortic regurgitation 37 

blood pressure in diagnosis of 37 

pulse pressure in 38 

Arterial pressure 8 

factors maintaining 8 

Arterial tonus 8 

B. 

Elood pressure 

age affecting 27 

alcohol affecting 30 

altitude affecting 26 

amplitude 13 

arte rial 13 

capillary 12 

car, ' 6 

1 j 

13 

digestion and 28 

. 12 

elastici y and 7 

emi 1 ing 29 

exercise affecting 28 

excitement affecting 29 

in aged 27 

in children 27 

methods of study of 9 

pathologic v-afiations of 34 

high pressure 34 

causes of 34 

low pressure 3^ 

posture affecting 26 

power of 7 



INDEX— Continued. 

pulse pressure 13. 

mean 14 

range 13 

reducers ^3 

regulating mechanism 7 

sex affecting 26 

systolic . 13 

time of day affecting 2K 

tobacco affecting 3c 

variations in 25 

Blood pressure in 

angina pectoris 4* 

acute anemia of brain 34 

acute nephritis , 35 

aortic regurgitation 37 

arterio-sclerosis . . . . 30 

asphyxia 3-1 

cerebral hemorrnage 45 

chrome myocarditis 30 

diabetes 47 

diseases of heart • 37 

defective metabolism S5 

diphtheria 4 > 

eclampsia 47 

exophthalmic goitre 46 

infectious diseases 49 

lead colic 34 

life insurance 5& 

neurasthenia 50 

peritonitis 34 

polycythemia . 50 

ocular hemorrhage V. 4< 

renal disease 12 

scarlet fever \g 

surgical shock 36 

surgery 55 

tachycardia 40 

typhoid fever 49 

uremia 45 

valvular lesions 37 



C. 

Cardio-vascular renal disease 42 

arteries in 42 

causes of 43 

diagnosis of 44 

pathology of 43 

sphygmomanometer in 42 

Cerebral hemorrhage 4; 

Chronic myocarditis . 37 



INDEX-- Continued. 

diagnosis of ' 37 

tests for 3° 

Circulation 3- 

causes of 4 

causes of pressure in 6 

course of 3 

How of blood in 4 

mechanics of 5 

regulating mechanism of .7 

Course of the blood 3 

D. 

Diabetes mellitis 4; 

Diastolic pressure 13 

explanation of 17 

Diet in hypertension 54 

Diphtheria, pressure in 40 

Diseases of the heart 37 

angina pectoris 40 

aortic regurgitation ^y 

blood pressure in 37 

chronic myocarditis 38 

tachycardia 40 

E. 

F.clampsia 40 

blood pressure in 47 

Exophthalmic goitre 46 

blood pressure in 47 

F. 

F.ow of the blood 4 

causes of 4 

H. 

Heart disease 2>7 

angina pectoris 40 

aortic regurgitation 37 

blood pressure in 37 

chronic myocarditis 3$ 

tachycardia 40 

Hypertension 34 

diet in ' 54 

transcient albuminuria in 60 

I. 

Infectious diseases 40 

blood pressure in 48 



INDEX— Continued. 

L. 

Life insurance examinations 58 

blood pressure in -g 

transient albuminuria in 5o 

M. 

Manometers 9 

mercurial 10 

Mean pressure 14 

Mechanics of the circulation 5 



N. 

Neurasthenia ^o 

blood pressure in 50 



O. 

Ocular hemorrhage -. . 46 

blood pressure in 46 



P. 

Pathoh >gic blood pressure 34 

hypertension 34 

hypotension 35 

Physiologic variations 25 

Polycythemia 50 

Posture affecting blood pressure 26 

Pulse, arterial 1 1 

Pulse pressure 13 

Pulse tracing T3 

R. 

Penal disease 4 2 

arteries in -'■ 

causes of !3 

diagnosis of • ■ 44 

path olpgy of . 43 

sphygmomanometer in 42 

S. 

Scarlet fever, pressure in 49 

Sphygmomanometer 14 

anaeroid '9 

diast< >lic reading of 22 

directions for using 21 



IXDEX-Concluckd. 

Faugbt's mercury 19 

method of using ' 18 

principle of 14 

record blank form 24 

readings of 18 

spring 19 

systolic reading 22 

varieties of 19 

surgical application of 55 

in venesection . \ 55 

in aneurism 55 

in pleural effusion 56 

in ophthalmology 55 

Systolic reading 13 

explanation of 17 

T. 

Tachycardia 40 

Therapeutics 50 

in apoplexy 52 

in hemorrhage 51 

in hypotension 51 

in nephritis 52 

Tobacco on blood pressure 30 

Transient albuminuria 6c 

Typhoid fever 40 

U. 

Uremia 45 

blood pressure in 4 = 



The Faught Blood Pressure Apparatus 

Simple, Compact, Durable, Easy to Use 

Always ready to use ; time required for the observation reduced to 
a minimum; no preliminary adjustment of the apparatus required; mercury 
can not be spilled; no detachable parts to be lost. 



An Invaluable Aid In Diagnosis, Prognosis and Treatment 

Indispensable to the General Practitioner, the Internal Specialist, 
the Surgeon, the Oculist, the Laryngologist, the Otologist, the Gynaecol- 
ogist, the Obstetrician and Student of Medicine. 





H3l3 


11 




I 

1 






1 


st® 




« f|5^ 



With the practical knowledge of these short-comings, the FAUGHT 
SPHYGMOMANOMETER has been devised. This Instrument embodies 
the essentials of the earlier instruments while omitting unnecessary com- 
plicity in construction. Thus eliminating the objectionable features, and 
reducing, to a minimum, the time required for observations. 



FOR SALE BY ALL SURGICAL INSTRUMENT DEALERS 



Complete, With Arm-Band and Bulb or Metal Pump in Mahogany Case — With 
Signed Certificate of Dr. Faught 

FIXED PRICES 

With Kubber Bulb $18.00 Net With Metal Pump $20.00 Net 



PATENTED AND MADE ONLY BY 

GEO. P. PILLING & SON CO, 

PHILADELPHIA, U. S. A. 

DEL. TO CAT OW. 

NOV 6 I9l« 



mommmi. 



n m:mki tf fuoatioi: 



; ::j ■-..: 



